Sample Name: Orthopedic Consult - 5
Description: Patient with back and hip pain.
(Medical Transcription Sample Report)
Chief Complaint: Back and hip pain.
History of Present Illness: The patient is a 73 year old Caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppression, peripheral vascular disease with non-healing ulcer of right great toe, and peripheral neuropathy who initially presented to his primary care physician in May 2001 with complaints of low back pain and bilateral hip pain. The pain was described as a constant pain in the middle to lower back and hips. The pain was exacerbated by climbing stairs and in the morning after sleeping. He reported occasional radiation of pain from back into buttocks (greatest on the right side). He has history of chronic feet and leg numbness and paraesthesias related to his neuropathy, but he denied any recent changes in these symptoms in relation to the back pain. He denied any history of trauma. He was treated symptomatically with Acetaminophen with only some relief. He continued to complain intermittently of pain in his back and hips, and occasionally even in his elbows during the next 8 months. In January 2002, plain pelvic films showed no fracture or dislocation of the hips. Elbow films also showed no acute injury, but there were some erosions along the posterior aspect of the olecranon. An MRI was performed of his lumbar spine which showed degenerative disk disease, spondylosis, and annular bulging/herniation at L4-L5 with resultant encroachment on the neural foramen. He was evaluated by neurosurgery, who felt he should not have surgery at this time. His pain continued and progressively worsened, becoming unresponsive to medical therapy including narcotics
In May 2002, as part of a vascular work-up for the patient’s non-healing right toe, an MRA showed extensive vascular disease in the vessels of both legs below the knees and evidence of bilateral trochanteric bursitis. It also revealed an abnormal enhancing lesion in the left proximal femur, the left iliac bone, the right iliac bone, and possibly the right tibia.
Past Medical History:
End stade renal disease secondary to reflux nephropathy
b. hemodialysis (1983-1988)
c. s/p cadaveric renal transplant (1988)
d. baseline creatinine about 2.3.
a. history of right foot infected toenail and non-healing ulcer since 2000; receiving hyperbaric oxygen therapy; recent surgery on infected toe in March, 2002
Chronic anemia (on Epogen injections)
History of several partial small bowel obstructions - six times during the last 10 years
1. Tonsillectomy and adenoidectomy (1943)
2. Left ureter re-implantation (1960)
3. Repair of splenic artery aneurysm (1968)
4. Left arm AV fistula graft placement and numerous procedures for dialysis access (1983-1988)
5. Cadaveric renal transplant (1988)
6. Cataract surgery in bilateral eyes
1. Imuran 100mg po QD
2. Prednisone 7.5mg po QD
3. Aspirin 81mg po QD
4. Trental 400mg po TID
5. Norvasc 5mg po BID
6. Prinivil 20mg po BID
7. Hydralazine 50mg po Q6H
8. Clonidine TTS III on Thursdays
9. Terasozin 5mg po BID
10. Elavil 30mg po QHS
11. Vicodin 1-2tabs po Q6H prn
12. Epoetin SR 10,000Units SQ QM and F
13. Sodium bicarbonate 648mg po QD
14. Calcium carbonate 2gm po QID
15. Docusate sodium 100mg po QD
16. Chocolate Ensure one can po QID
18. Vitamin E
Social History: The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse.
Allergies: No known drug allergies.
Family History: : His father died of colon and thyroid cancers at age 52. One brother died of stomach cancer at age 53 and one brother committed suicide. Five other siblings are all healthy. Negative for coronary heart disease, hypertension, diabetes, or kidney disease.
Review of systems: Denies fever, chills. Reports 15 to 20 pound weight loss slowly over 10 years (no recent change). Occasional mild shortness of breath with exercising. Denies chest pain, cough, abdominal pain, nausea, vomiting, recent change in baseline bowel movements, or dysuria. Denies any bleeding. Several year history of erectile dysfunction.
Physical Exam: BP - 124/70, HR - 72, RR - 14, T - 97.8
Gen: Well nourished, pleasant male in no acute distress.
HEENT: Extra-ocular muscles intact. Pupils equal, round, and reactive to light. Oropharynx clear. No funduscopic exam recorded.
Neck: Supple. No thyromegaly, bruits, or elevation of jugular venous pressure.
Lungs: Clear to auscultation bilaterally.
CV: Regular rate and rhythm. 1/6 systolic ejection murmur at left sternal border. No gallops, rubs, or clicks. Normal pulses.
Abd: Soft and non-distended. Non-tender. Normoactive bowel sounds in all four quadrants. Midline surgical scar. Kidney palpable in left lower quadrant. No hepatosplenomegaly and no masses.
Exts: No cyanosis, clubbing, or edema. Right great toe ulcer on medial aspect, mildly erythematous but no drainage.
Back: Some pain with palpation over left iliac bone.
Rectal: Normal sphincter tone. Prostate smooth with no nodules.
Skin: No lesions.
Lymph nodes: No lymphadenopathy.
Neuro: Alert and oriented. No focal deficits. DTRs 1+ bilaterally. Strength 5/5.
1/02 MRI Lumbar spine without contrast:
1. Spondylosis at L2-3 with marked narrowing of the disk space, grade I/IV degenerative retrolisthesis, and moderately severe central spinal canal and bilateral foraminal stenosis.
2. Degenerative disk disease at L4-5 with diffuse annular bulging and a broad based right lateral foraminal and extra-foraminal far lateral herniation which results in significant encroachment on the right lateral recess and neural foramen, and this deserves clinical correlation for right L4 and L5 radiculopathy. Degenerative facet joint changes and ligamentum flavum thickening are noted bilaterally at this level, but the central canal is adequate.
3. Spondylosis with annular bulging and facet joint degenerative disease at L5-S1, L3-L4, and L1-L2 to a mild degree without significant stenosis.
4. Note is made of probable cyst of the upper pole of the right kidney which measures 1.8cm in diameter. There is decrease in size of the right kidney which may be due to chronic renal disease.
1/02 Left Elbow Films (2 views):
Rather extensive vascular calcification in the soft tissues. There is no evidence of an acute injury. There is, however, what appears to be some erosion along the posterior aspect of the olecranon.
1/02 Pelvis films:
There is no fracture or dislocation of the hip identified. Extensive vascular calcification noted.
5/02 MRA Lower Extremity with and without contrast:
1. Minimal atherosclerotic narrowing of the bilateral superficial femoral arteries. Severe atherosclerotic disease of bilateral popliteal, anterior tibial, peroneal, and posterior tibial arteries (right greater than left).
2. Abnormal enhancing lesion in the left proximal femur, the left iliac bone, and the right iliac bone. There may be a similar lesion in the right tibia.
3. Abnormal enhancement in the trochanteric bursa of both femurs consistent with bursitis.
4. The vertebral bodies demonstrate abnormal enhancement adjacent to the end-plates likely due to degenerative disk disease. There are questionable abnormal enhancing lesions in the vertebral bodies.
6/02 Chest X-ray
There are no compression fractures identified. The lungs are adequately expanded. Two densities in right hemithorax that appear to represent healing rib fractures. The one involving the right 7th rib posteriorly could be a pathologic fracture. No lung nodules or lymphadenopathy.
6/02 Whole Body Bone Scan:
Areas of increased tracer activity are noted in the right proximal humerus, the left scapula at the region of the glenoid, the anterior aspect of the right third rib, the posterior aspect of the sixth, seventh, eighth, and ninth ribs, the left lateral aspect of the T10 vertebra, the L3 vertebra, the right lateral aspect of the L5 vertebra, the left iliac crest, both SI joints, the right ischial bone, the left proximal and mid femur, the right distal femur and the left proximal tibia.
Irregular tracer activity is noted in the cervical and thoracic spine consistent with degenerative changes.
Tracer in the left lower quadrant of the abdomen consistent with a kidney transplant.
A diagnostic procedure was performed as an outpatient on 7/10/02.
Keywords: orthopedic, hip pain, hypertension, end-stage renal disease, reflux nephropathy, cadaveric renal transplant, vascular calcification, abnormal enhancement, vertebral bodies, iliac bone, hemodialysis, posterior,